UNCORRECTED TRANSCRIPT OF ORAL EVIDENCE To be published as HC 289-iv

House of COMMONS

MINUTES OF EVIDENCE

TAKEN BEFORE

health Committee

dentaL services

THURSDAY 6 mARCH 2008

DR ANTHONY HALPERIN and MS TERESA PERCHARD

ANN KEEN MP, MR BARRY COCKCROFT and MR DAVID LYE

Evidence heard in Public Questions 641 - 837

USE OF THE TRANSCRIPT

Oral Evidence

Taken before the Health Committee

on Thursday 6 March 2008

Members present

Mr Kevin Barron, in the Chair

Charlotte Atkins

Sandra Gidley

Stephen Hesford

Dr Doug Naysmith

Mr Lee Scott

Dr Richard Taylor

________________

Witnesses: Dr Anthony Halperin, Chairman, Patients Association and Ms Teresa Perchard, Policy Director, Citizens Advice Bureau, gave evidence.

Q641 Chairman: Good morning. Could I welcome you to what is our fourth evidence session in relation to our inquiry into dental services. I wonder if I could ask you to introduce yourselves and the positions you hold for the record, please.

Ms Perchard: My name is Teresa Perchard; I am Director of Public Policy at Citizens Advice which represents Citizens Advice Bureaus throughout England and Wales.

Dr Halperin: My name is Dr Anthony Halperin; I am the Chair of the Patients Association and I am also a practising dentist although not currently an NHS practising dentist.

Q642 Chairman: Could I just ask you about the Patients Association as an organisation? Is it membership based?

Dr Halperin: Patients can become members of the Patients Association but they do not have to be members to be represented. We represent all patients' interests in this country so I suppose we represent them whether they like to be represented or not in a way. What we are basically looking after is the health and care given to patients in this country, medical, dental, optical and pharmaceutical.

Q643 Chairman: How do you engage with patients? Outside of these hearings I never meet anybody from the Patients Association. I quite regularly meet people in South Yorkshire where I represent - patient advocates and PPIs and different things - but how do you engage with patients?

Dr Halperin: That is a very good point. We were founded by our President Claire Rayner probably about 40 years ago and we have a small office staff and we have a helpline where anyone in the country can phone in with any problems they have. I suppose our main contact with patients is firstly via our helpline and secondly via surveys we carry out not only for ourselves but normally sponsored by groups - ie pharmaceuticals, dental groups, medical groups - who want surveys to be carried out, and therefore we interview patients and give a statistical feedback.

Q644 Chairman: Would you call yourselves a representative body?

Dr Halperin: We consider ourselves a representative body; whether the public see us as a representative body I do not know, but at the present time, since most of the patient groups in this country have tended to be dissolved or have no longer got the funding, really we are probably the only actual national patients' voice left.

Q645 Chairman: There are organisations that represent people with MS that are representative in that sense. If the MS Society contacted me here in London it is very likely I would know members of their Society from my constituency. Indeed I do and I interact with them but not with members of your Association. When I talk about representativeness that is the type of shape I mean. I do not get any feedback of Patients Association members in the Rother Valley.

Dr Halperin: We do have thousands of actual members who are patients or members of the public, but I suppose even thousands is a small percentage. Most people in the country have heard of us because we are almost constantly in the media representing one form of patient or the other.

Q646 Mr Scott: How do you become a chairman? Do the members vote you as chairman?

Dr Halperin: There was an appointment made for trustees and I was appointed a trustee about four or five years ago and then when Michael Summers, the former Chairman, stepped down, I was elected as Chair of the Board of Trustees.

Q647 Mr Scott: How many trustees are there?

Dr Halperin: We have about seven or eight trustees.

Q648 Chairman: You have launched this report on NHS dentistry by PCTs, could you tell us who you surveyed and what were the report's main findings? We do have copies of the report but we have not had time to read them; I have your press release from yesterday so maybe you could talk to us around that.

Dr Halperin: The main findings were that there was quite a variation in the answers from PCTs as to the funding they were able to produce, as to the satisfaction of dentists within the PCTs. We had a 75% response - 25% of the PCTs did not respond which they should have done under the Freedom of Data Act - and there was considerable concern from the dentists working for the PCTs as to whether or not they were happy with their new contract. The PCTs themselves seemed to be happier with the actions they were undertaking than the dentists. There were concerns with the orthodontic treatment particularly; access was a problem; there was a lack of patient involvement as well.

Q649 Chairman: One of the bullet points in your press release said that there was widespread confusion for patients about access to dental services in their locality. Did you actually survey patients as well as the PCTs?

Dr Halperin: No, only the PCTs were surveyed.

Q650 Chairman: How do you know there was widespread confusion for patients if that was not measured?

Dr Halperin: I have been informed that it came from our helpline enquiries.

Q651 Chairman: Not from the survey that this press release talks about.

Dr Halperin: Not from the survey, no.

Q652 Chairman: A bit further down you say that the Patients Association calls on the Government to "examine the accepted co-payments system for dentistry as the basis for expanding the availability of treatments elsewhere in the NHS eg non-NICE approved drugs". What has that got to do with dentistry?

Dr Halperin: I personally did not put that part in.

Q653 Chairman: It is just a bit confusing. Do not get me wrong, I actually think that your survey could be quite helpful to the Committee because outside of the department survey of PCTs nobody else has done it. It is quite wide ranging and I am sure that some of my colleagues may want to ask questions about your survey as well. However, it does seem to confuse matters a little bit when we have things like that in.

Dr Halperin: I not necessarily agree with the view of co-payment; not all trustees think the same way.

Q654 Chairman: I was just wondering what the issue about co-payment about NICE approved drugs or non-NICE approved drugs has got to do with dentistry.

Dr Halperin: I would have said non whatsoever.

Q655 Chairman: Let us move on from that. What do you think in general terms your survey revealed about patients' access to NHS dentistry?

Dr Halperin: I think it varies. The problem is that although we put out these surveys to the PCTs asking for specific responses from a specific person obviously it was not carried out by that person. We are not sure of the level of expertise of the people at the PCTs that responded to our survey. I am not certain that when they say that patients are basically happy with access where that comes from. I am concerned that our survey may not be accurately based on the PCTs having an accurate survey or whether there was somebody just ticking boxes because they felt that was the right answer.

Q656 Stephen Hesford: Just so we are clear, the report was sponsored or your group is sponsored by Denplan and AXA insurance.

Dr Halperin: Yes.

Q657 Stephen Hesford: In terms of your organisation, you sort of exist as a survey organisation, is that right?

Dr Halperin: No, we are a charity. Like all charities we have substantial difficulty existing because of funding. We have always tried to make it a principle that we do not take government money per se because we wish to be completely independent. If you are a cancer charity or an Alzheimer's charity or whatever then patients relate to that charity. We have a great difficulty representing patients because although we think we do a good job in MRSA and other matters it is not something for which we can go out with a collecting box. Therefore we rely on our funding from sponsors in two ways. Firstly, sponsors such as the large pharmaceuticals, dental companies or building companies become a sponsor with quite a small amount of money. Secondly, on their behalf and in their specific fields, we carry out surveys. So our funding is from carrying out surveys - a little bit like the King's Fund carries out surveys - and although we are not survey based we rely on surveys as part of our funding. However, we never take any note of who is supplying the money; our surveys are completely independent and that applies especially to pharmaceuticals; our pharmaceutical supporters completely understand that whatever the results of the survey it is going to be published.

Q658 Stephen Hesford: Do you not think if unfortunate that of all the funders that you could have had to help you do a survey on dentistry that Denplan is one of the funders in terms of looking as though you are independent?

Dr Halperin: I used to be a Denplan arbitrator and do the arbitrations for Denplan. I did the arbitrations totally and completely independent. This was 20 years ago and so no longer applies but I must tell you that I have found them to be completely independent. This is not a push for Denplan but of all the organisations they are as independent as anyone; they have never once tried to influence our decisions.

Q659 Stephen Hesford: In terms of your personal position, looking at your biography, you are the Chief Dental Advisor to Guardian Health.

Dr Halperin: Actually that is now an old one. I just advise all the insurance companies. I am no longer a specific dental advisor for them. I act for all insurers but only in the capacity of an expert witness. I have no paid capacity with AXA or Guardian Health.

Q660 Stephen Hesford: In terms of the timing of the launch of your report, I received an e-mail yesterday from somebody called Vanessa Vaughan inviting me to the launch of your report. I e-mailed Vanessa back about this. As a member of this Committee how does your organisation think I could, with credibility, have gone to the launch of your report knowing that we are in the middle of an inquiry on dentistry and about to receive your evidence minutes after the launch of your report?

Dr Halperin: We are an independent report; why would you not want to go? I am sorry; I do not understand the question. If we give an independent report I see absolutely no reason why you should not want to hear what it is. I really do not see any connection between the two.

Q661 Stephen Hesford: Your press release talked in these terms: "Katherine Murphy, Director of Communications commenting on the Report said: 'Patients are taxed more than ever to provide their health services'." What is the point of that language?

Dr Halperin: You may not agree with the report, but I believe that as an independent observer - we had Ross Hamberg speaking there who actually thought the PCTs did an excellent job and she was very happy with the work of the PCTs; we had opposing views as to whether the PCTs were doing a good job or were not - we always try to make sure that we have a different point of view.

Q662 Stephen Hesford: What is the point in making a comment in terms of surveying PCTs about the issue of taxation?

Dr Halperin: I did not make that particular one so I will not comment on it.

Stephen Hesford: The woman sitting behind you did.

Chairman: Could we move on because she is not giving evidence here.

Q663 Dr Naysmith: I was rather surprised, Dr Halperin, when you were talking about your survey and you said that you were not sure whether some of it might have been people just ticking boxes because they thought they had to or because they thought it was the right thing to do. How reliable and accurate do you think your survey actually is?

Dr Halperin: I think the survey overall is accurate. It can only be as accurate as the answers we get as with any survey. I think it is the problem with any survey you carry out, you just have to rely on the answers you are given, we cannot go any further than that. We have carried out a survey and we have given the response from the PCTs which are nationally funded bodies and hope that their evidence is reliable.

Q664 Dr Naysmith: That does not mean that you can necessarily be certain that every reply is accurate, therefore the figures you have derived from it may not be accurate.

Dr Halperin: I agree but I think you can say on the balance of probability most of them would be correct. This is the problem with any statistical survey, you can only rely on the answers you get.

Dr Naysmith: You have a refreshing attitude to the results of your survey.

Q665 Charlotte Atkins: Teresa, according to your survey 31% of people who had not visited a dentist since April 2006 had been able to find a dentist in their area. By that I assume you mean an NHS dentist.

Ms Perchard: Yes.

Q666 Charlotte Atkins: How does that compare with the situation before April 2006?

Ms Perchard: You have been bombarded with surveys, including from us actually, and I am very conscious in trying to bring them together to see what direction they are pointing in, some things are saying some things more loudly than others. We advise on 6000 dental problems in bureaus face to face and those are split between access and charging issues really; those are the two big issues, the inability to find a dentist and charges are also a bit issue for people who come to CABs. When we have most recently gone out and asked the public at large in a MORI survey - which are the results you have just highlighted - the charging issue is not so big for the population at large. To pick up on my colleague's point about surveys, who you are asking and the context in which you are asking can produce a different result. We have done three pieces of survey work, firstly looking at evidence from bureaus in their advice work, that is the 6000 and then nearly 5000 people who filled in a survey form on line with Citizens Advice; they were using information that we have on line to try to resolve a problem they had so by definition they are not the people on the streets that you might ask to do a MORI survey who have not really thought about this issue recently, they are people looking for information to resolve a problem. For them the issues of access and charges were much more significant than the population at large. Across all of the bits of research that seem to be around, including the Government's own figures, I would say there is a really strong message pointing to no improvement in access and take up of NHS dentistry.

Q667 Charlotte Atkins: Since the new contract, is that what you are saying?

Ms Perchard: What is driving this? Is it the new contract or is it the way that services are actually being commissioned by PCTs? We think the root of the problem here is that the new pattern of services really is the old pattern of services because PCTs went into the new contract without really going and looking afresh at what the need was, where the gaps are and how to help fill them. That is what we think needs to happen to address this. There has been no redistribution between PCT areas that have adequate access and those that have inadequate access. That is why we have welcomed the Government's announcement to retain the ring fence over NHS dentistry spend by PCTs (because without a ring fence it might move into other areas of investment) and to increase by 11% the amount for NHS dentistry which is a more significant increase of PCT spending as a whole. We think that that, coupled with the new duty on PCTs, makes it their duty to ensure that needs for NHS dentistry in their area are met and should give them the oomph and the cash to do their best to match supply to demand. I think what has been highlighted by the Patients Association's survey, going directly to PCTs which we have not done, is that variability in the PCTs' approaches. We think that is where more work needs to take place.

Q668 Charlotte Atkins: Your survey rather alarmingly said that 7.4 million people were being denied NHS dentistry. That was based on extrapolation obviously of your survey of just under 2000 adults and given what you said about variability does it make sense to extrapolate 7.4 million just from that survey of just under 2000 adults?

Ms Perchard: It is a representative survey conducted by MORI, a well-known independent research organisation. Before we published it we had considerable discussion with the Department about the doing of the survey and the conclusions we might draw from it. We asked a number of different questions. There was a bigger question that found that 35% of the population had not been to a dentist at all in the previous 18 months and that might raise questions about the general use of dental services, private or NHS, and whether there is a growing problem with people not having adequate check ups and the implications for preventing dental health problems arising. Of those who had not had NHS treatment - 54% - 31% of those said it was because they could not find one; 30% said they did not think they needed to go for treatment. The 31% who could not find an NHS dentist is equivalent to 7.4 million people. The department knew this and did not raise any objections to our conclusion. Of those, 4.7 million went privately and paid and were not actually concerned about paying to do so. We could have a long debate about whether they should or should not have. Our real concern is the 2.7 million people who went without, who wanted to go the dentist, wanted to use an NHS dentist, could not find one and then did not go private. They did not go to the dentist at all because they could not find an NHS dentist and presumably could not afford or there may have been some distance issues around access as well; it was just not accessible to them. The Department of Health was thinking there were about two million people a couple of years ago who were missing out on NHS dentistry and we roughly got the same numbers; there is not a lot of distance between us and the Department about that, 2 million and 2.7 million. I am conscious that there are a lot of numbers in this debate and you cannot stick them all together because they are asking different people in different contexts at different times. We were very involved in the run up to the reform of NHS dentistry; we are represented on the group led by Harry Cayton to come up with a much simpler system of banded charges which means there is a lower limit for charges. We generally backed the direction of travel here on the reform to the contract, the reform to charges and we are very pleased the Government is now putting more money into NHS dentistry and giving PCTs a duty. We want to see that work; we want to see PCTs get on and do a better job than they are doing. Our evidence is provided really to help people see where the problems may be so that they can do their job.

Q669 Charlotte Atkins: Do you think that the money from the Government to PCTs should be spread evenly across the country in terms of increasing dental access? You have recognised in your survey that there are quite big variations over the country and you also said that present availability of dentists is very much based on a historic model.

Ms Perchard: In our MORI survey - the one we have most recently published and sent you a supplementary submission on - we highlighted the southwest and the northwest as being significantly above average in people being unable to find an NHS dentist. Ideally the extra money should be targeted on areas of most need.

Q670 Charlotte Atkins: Do you mean the extra 2%?

Ms Perchard: If the increase in investment is intended to help PCTs address the needs of two million - if you are the Department - or 2.7 million - if you are us - people who wanted NHS dentistry and went without because they could not get it, then ideally you should be focussing that on the areas in most needs. We are not aware of any mapping that has been done by PCTs themselves or the Government to identify where those dental deserts might be. In the absence of that, making sure that all PCTs feel they have more comfort around their financing in order to start doing that, because all the answers from the Government on this is that this is a matter for PCTs to identify what the needs are in their area and set out to meet them, and they are being given enough resources to do so. We would dearly love to see a map of England and Wales showing where the biggest problem areas are and to see investment distributed accordingly but in the absence of that what can we expect?

Q671 Sandra Gidley: I was at the launch this morning because for the life of me I cannot see the difference between reading a report in the public domain and going along to hear what is being said about a report in the public domain and it all informs the debate as far as I am concerned and we can take out own judgments on that. Dr Halperin, you mentioned orthodontics particularly and that is what I wanted to come onto next, to ask about what your surveys revealed about orthodontic treatment. We have heard some evidence that certain areas or regions of the country are better or worse for orthodontic access. I do not think it is quite as simple as that because in my patch Southampton is abysmal and Hampshire is relatively good; you cross the border and you get a completely different picture. What do the surveys reveal?

Dr Halperin: To question 18a: "Has the PCT put additional money into the provision of orthodontic treatment?" 34.7% said yes and 65.3% said no. I think it is a deeper problem than that. I am not an orthodontist but I have followed what the orthodontists are saying about the problems and whereas before, under the old contract, orthodontists did not have free reign but they were allowed to carry out a very wide variety of orthodontic treatment, our helpline has a number of calls into it now saying that their children just cannot get orthodontic treatment because the new criteria means that they have to fall into certain guidelines. The danger from the patient's aspect is that when you set guidelines for what children can receive and what they cannot receive it tends to be very arbitrary. From a psychological point of view one child may not be worried at all if his tooth is slightly crooked whereas another child may be severely traumatised or feel they are being made fun of. Whereas originally orthodontics was, as I said, fairly freely available as long as the Dental Practice Board felt that it was appropriate - and most of the time if the dentist thought it was then it was allowed - under these new guidelines it is not just a question of money for orthodontic treatment it is the guidelines for orthodontic treatment that have been altered. For instance, we have a case where a mother has twins with identical orthodontic problems and, because of a date of a couple of weeks in the new contract, one twin is allowed to receive treatment under the old contract whereas under the new contract when it came in the other twin is not receiving it because they do not fall within the guidelines. I think it is more than a problem of funding; it is a problem of guidelines for what children may receive and I think this does need to be looked at so that children do not have trauma as a result of misaligned teeth. I am not talking just about dental trauma, I am talking about psychological trauma. Children are very aware of being made fun of by other children if something is not right about them. If they have treatment later on it can be far more complicated.

Q672 Sandra Gidley: The answer to question 14c shows that orthodontics is in the top three of the number of complaints received by trusts over the country. Are you convinced that it is just an access problem which forms the basis of the complaints or is it a quality problem?

Dr Halperin: I think it is a quality problem. This is one of the problems I have with the new contract - and not just with orthodontics - that because the quality guidelines have been taken away by the fact that the dental reference officers are no longer able to inspect patients and thereby the quality of treatment by dentists, we are going to have a quality problem under this new contract; there is no question about it, it is there already.

Q673 Sandra Gidley: Teresa, does your survey highlight this?

Ms Perchard: Not specifically on orthodontics but what I have spotted really is an emerging issue around quality and satisfaction. Certainly in terms of people coming to bureaus for advice quality of service is not the issue they are coming about; they are coming about help with costs and finding a dentist. In the online survey we did last year which 5000 people completed 32% said they were not happy with the quality and we highlighted that in our first evidence submission to you. In some senses people's dissatisfaction seems to be arising from a very busy, pressed service which is looking perhaps to tightly ration what it is that is being offered to the customer. That may be an impact of the new contract or not and I suspect it is highly variable from practice to practice and how under pressure the practice is. That underlines the postcode nature of this problem.

Q674 Dr Taylor: Teresa, you said in your submission that PCTs "have adopted a narrow interpretation of their new duties". Is that what you meant when you said earlier that they did not look afresh at how to fill the gaps?

Ms Perchard: Yes, it is.

Q675 Dr Taylor: You said they need oomph and cash.

Ms Perchard: We think that all PCTs should be undertaking surveys to establish how much unmet demand is out there. Even looking at the very simple short survey we have done with MORI it is quite possible to ask people whether they had gone to a dentist, who they went to, whether they prefer NHS dentistry; had they tried and did they find it difficult; you can ask people those questions quite easily. We also think that PCTs should have a look at developing some standards for accessibility of services, particularly focussing on travelling time and distances. In the areas we highlighted where access seems to be the worst - the southwest and the northwest, rural areas, poor public transport, dispersed communities -a PCT really ought to have a view about where all the access points for dentistry are in their geography and realistically how potential patients are likely to be able to access their services and if something needs to be improved then to put that in place. Generally we think PCTs ought to be doing some more proactive things around promoting NHS dentistry services.

Q676 Dr Taylor: Would you agree with one of the points in Dr Halperin's paper that one course to action is where PCTs offer an excellent creative commissioning structure they should take over the dental commissioning role of those that do not?

Ms Perchard: I have no comment to make on that.

Q677 Dr Taylor: Is that feasible?

Dr Halperin: I am not sure it can be feasible.

Ms Perchard: If you are giving an organisation a job to distribute public funding and to achieve a certain welfare goal and it is not doing a good job compared to others, we need to know what is going on and take a view on it. Whether you ask someone else to step in and do it if they are failing, there may be other options for remedies. I think consumers would like to know that somebody is keeping an eye on what is going on and taking action to remedy problems.

Q678 Dr Taylor: To change tack for a moment, do either of you have any evidence about patients' attitude to registration?

Dr Halperin: Yes, I have got quite strong views on that.

Q679 Dr Taylor: What about your patients?

Dr Halperin: Having treated patients for more years than I like to think about, patients do care about seeing the same dentist or doctor. I believe that on-going registration which has now been taken away is absolutely vital not only for the relationship with the patient but the relationship with the dentist, that he has on-going, continuous records of treatment; that he builds up a relationship with a patient and the family over many years. What we have now is that effectively as soon as a course of treatment is finished that patient is no longer a member of the practice; it is almost like going into a supermarket and starting all over again. I do not really understand why we have taken that personal relationship away which was good for the patient, good for the dentist and good for treatment.

Q680 Dr Taylor: If there is a problem after that course of treatment the patient does not know where to go with it.

Dr Halperin: They can possibly go back to the same dentist but they are not a registered patient with that dentist.

Q681 Dr Taylor: Would you agree?

Ms Perchard: We have not specifically asked people what they would prefer. I think those points are quite compelling, particularly where people may find it difficult to get treatment and people who have location difficulties may need more support. Being on a list and somebody keeping the records and there being that track record of your engagement with dental services may be quite helpful for certain individuals. For those people who are happy to go to Tesco or Sainsbury and go to the dentist and those people who are happy to shop around and are very confident to do so then requiring them to be on a list may be inappropriate. For some patients that supportive approach is likely to be in their best interests and in the best interests of the dental health of the nation.

Q682 Mr Scott: The CAB reports that a quarter of people have cited charges as a reason for not visiting a dentist. I believe there was one person who pulled out nine teeth with pliers; they may need more help than a dentist if they are going to pull out nine teeth with a pair of pliers. How can low income earners be helped to meet these expenses of NHS dentistry?

Dr Halperin: I think the problem is that there may be a gap between those patients who are exempt charges and those patients who are not exempt charges but have difficulty in meeting the household budget. I think the other problem is that the bands are really quite poorly understood. I know it was supposed to mean simplification. I am not an NHS dentist but I am a dentist and I have been looking at these bands and even now if somebody asked me to say exactly what falls into what band as far as a charge is concerned I would probably be 75% right. That means a patient is probably only going to be 20% right. It is not quite that simple and probably patients do not understand why one filling would cost the same as six fillings. It appears to be irrational not only to the dentist but probably to the patient as well.

Ms Perchard: Certainly about a third of all our enquiries in bureaus seem to be concerning problems with charges, and often we are helping people to claim an exemption through the HC1/HC2 system and that suggests to us that there is quite a lot that could be done, particularly now, to improve awareness of the low income scheme. Indeed this is something that this Select Committee has highlighted in a previous report on health charges, looking at prescription charges as well, where it was quite clear that the number of applications under the low income scheme was declining. The general literature that is available on the new dental charges really is quite understated about how you could get an exemption or help with charges. Looking at passporting exemption to people receiving housing benefit, council tax benefit, might be helpful. In London there is some really interesting evidence come out of the Greater London Assembly. There is a good supply of dentists but people on very low incomes do not go to NHS dentists. It is not about getting more dentists in, it is about getting engagement from the public and part of that maybe that even though £198 is a maximum charge is too off-putting, but there may be help available and the low income scheme could be extended and also be much more widely promoted in some of those urban areas where there is good access in theory but some groups are not taking up dentistry and not going for check-ups as much as others. We have referred to that briefly in our evidence as well.

Q683 Dr Naysmith: Teresa, your survey reported that 32% of patients who had undergone band 2 treatment were not happy with the quality of care they received. What actually were they saying about it? What aspects of the treatment were they complaining about?

Ms Perchard: I think this is probably our online survey. This is where we have a big body of evidence of comments that people made. I think I would have to go back and have a look at what the main issues were. We have highlighted in the submission a few examples where people thought they were going to get one thing but got another; did not get as many fillings as they were told they would get and felt rushed through the process. We have supported the simplified banding scheme. You only have to look at the 400 different charges that there used to be to see that it is an absolute transformation, but I suspect you have to be quite a canny consumer to get a clean out of the band 1 and not be referred to the hygienist and have to pay £45 and actually to get everything that you are entitled to for your band 2 you probably need to be quite assertive. That is where the PCTs come in in promoting what you can expect from an NHS dentist and also doing a bit of compliance monitoring focussing on evidence from consumers about what actually happened when they did go to an NHS dentist.

Q684 Dr Naysmith: What are they actually saying? Are they saying that they do not get the number of fillings that they ought to get?

Ms Perchard: To answer you properly we would need to have a look at the free text comments that people made and see where the balance lies. Was it that they thought they would have more treatment or what.

Q685 Dr Naysmith: Or did they think they were paying for something and they were not getting value for money?

Ms Perchard: Yes, which could be as a result of not having had very much treatment. We will come back to you on that with a bit more information.

Q686 Dr Naysmith: That would be very helpful. Dr Halperin, your submission states that the contract has "excluded care by stealth". What do you mean by that? Was that something you wrote in?

Dr Halperin: I will give you a very short history of the NHS as I have observed it over the past 35 years. When the NHS first came in treatment was skewed by the fact that dentists got paid per filling per tooth and we saw a number of molar teeth with six separate little fillings in them. Over the years as the contract changed the various types of treatment a small percentage - I insist it is a very small percentage, 99% of dentists acted in a most proper manner - of dentists skewed the treatment. In my experience the treatment was sometimes distorted by the fee scale, ie for the type of filling you did you got a different payment. This was recognised by the Dental Practice Board who brought in very sophisticated monitoring techniques of which dentists did which fillings on which patients and they had quite a large fraud department to make sure that dentists did not do inappropriate treatments. One hoped, when the new contract came in, that this type of treatment geared to a financial reward - I will put it that way - was no longer there. Unfortunately I believe that under the new system that has come in it may be as bad or even worse. I am not talking about a treadmill effect so much as the fact that a dentist is presented with the same fee for one filling or six fillings; he is presented with the problem that if he carries out a root treatment it can take him an hour whereas if he takes out a tooth it can take five minutes. I believe this is an unfair onus on dentists that treatment and reward that they are given thereof is governed by an artificial system of payment.

Q687 Dr Naysmith: How is that exclusion by stealth of care?

Dr Halperin: It is an exclusion by stealth of care in that the patients may not be getting the best treatment under the new system because of the way the UDAs are geared, ie instead of getting the three crowns they need they may not get any crowns or they may get one crown.

Q688 Dr Naysmith: Do you think it is worse than the old system whereby people got their mouths filled unnecessarily?

Dr Halperin: I think it possibly is because there was a survey showing how many dentists they thought carried out treatment that was inappropriate and it was very tiny; it was well under 1%, ie the majority of dentists under the old system did carry out appropriate treatment. What we do not know under the new system from the patients' point of view - because of the safeguards so far as monitoring patients care have now been taken away because we no longer have any regional dental officers independently inspecting - is the quality of care they are getting. All we do know is that the amount of crown and bridge work has gone down substantially and my view is that patients do need crown and bridge work as they get older. It is by stealth, if you like, the way the contract has been brought in; it may not have been the intention but I think it has happened.

Q689 Dr Naysmith: Thank you; that was a very full explanation. Have either of you got any evidence of patients being referred unnecessarily to hospitals for treatment.

Dr Halperin: I have evidence of one of our patients on the helpline who went to the dentist and the dentist said, "I am sorry, you need a root treatment and I am afraid I am unable to carry this out". He was an elderly gentlemen, I think he was in his 70s, and he was referred to a private dentist down the road who then carried out the root treatment and charged him £175. He then complained to the PCT who refunded him £100. I do not know under what system he was refunded - I do not know how there was an appropriation in their budget for it - but he was given £100 back.

Q690 Dr Naysmith: The question was really whether he was referred to a dental hospital. Do you know of any cases?

Dr Halperin: No, I do not have any specific cases of that.

Ms Perchard: We have found it is more people taking themselves to hospitals because the PCT has told them they can go on the waiting list to go on the waiting list, or there are seven dentists on the website and none of them will take them. That is why we are interested in PCTs taking a more overt role in promoting the NHS dentistry services that are there and acting really as a proper information clearing house so that people can find quickly who can take them on now so as to avoid that displacement onto the hospital services.

Q691 Dr Taylor: To what extent do PCTs involve patients in determining how dental services are delivered in their area?

Ms Perchard: The things we have advocated around PCTs now, if they have not already, are starting to do some mapping to find out what the level of need is and also looking at setting access standards would engage the PCTs in talking to groups who can represent consumers and might provide the opportunity for more dialogue. The East of England Strategic Health Authority recently circulated a very good briefing to PCTs about promotion of the existing services; all calls to the helpline should be given at least three dentists who could take them on and also giving them a bit of a steer about how to set about finding out where the gaps are. I think in day to day practice I do not get the impression there is very lively discourse with consumer groups.

Q692 Dr Taylor: Does the CAB have a view on the change from patient forums to Links and could Links be more effective in helping, particularly in the dental field?

Ms Perchard: I do not feel able to comment on that at the moment, I am afraid.

Q693 Dr Taylor: Dr Halperin, has the Patients Association made any formal move to try to join in with Links which is supposed to link every patient body together?

Dr Halperin: Not as far as I am aware.

Q694 Dr Taylor: Had you beforehand any links with patient forums or patient participation groups?

Dr Halperin: We have had links in the past, yes.

Q695 Dr Taylor: Will you be looking at links with Links?

Dr Halperin: The Patients Association will always be interested in working with any groups that promote patients' interests.

Ms Perchard: Some CABs have run patient forums and that is good because the bureaus do a lot of advice in health settings; 1100 health settings have CABs doing outreach advice so there is a lot of proximity between our organisation and the health network.

Chairman: Thank you both very much indeed for coming along and helping us with our inquiry into dental services.

Witnesses: Ann Keen MP, Parliamentary Under Secretary of State for Health Services, Dr Barry Cockcroft, Chief Dental Officer and Mr David Lye, Head of Dentistry and Eye Care Services, Department of Health, gave evidence.

Q696 Chairman: Good morning and welcome to the Health Committee. I wonder if I could ask you if you could give you give us your name and the current position that you hold.

Mr Lye: My name is David Lye and I am Head of the Dental and Eye Care Branch of the Department of Health.

Ann Keen: I am Ann Keen, minister with responsibility for dentistry, Parliamentary Under Secretary of State.

Dr Cockcroft: Barry Cockcroft, Chief Dental Officer for England.

Q697 Chairman: Minister, welcome back. I do not know whether it is game keeper turned poacher or the other way round, but welcome back to the Health Select Committee which you were a member of for a while as I recall. Most of the questions that are going to be asked to day are going to be directed you, you will be really pleased to know. You may want to field them on occasions, but that is the general direction of this evidence session. I would like to start and ask you questions about implementing the contract. Looking back at this now, it is now nearly two years since it was implemented, do you agree it was a huge mistake to introduce the new contract at the same time that primary care trusts themselves were being re-organised in 2006?

Ann Keen: Thank you for your kind remarks at the beginning. It is good to be back; I enjoyed my time immensely on the Health Select Committee, a very important committee, and I really welcome your report. I want to start by saying that today because I think it will be very helpful to us. In relation to your question and was it a good time, the reforms had been long planned and the legislation was passed in 2003, so having that continued delay was causing uncertainty within dentistry. Was it the best time? When would there have been a best time? I do acknowledge, without question, that when re-organisation was taking place within PCTs that did cause PCT to have extra work and obviously then a much more challenging time.

Q698 Chairman: One of the things that has puzzled me and other members of the Committee as well over the weeks that we have been taking evidence now is that the form the new contract was agreed it was not piloted. In a sense you did not know what the reaction to the new contract would be either by the profession or by patients as well, particularly because of the changes in patient contributions. Why was it not piloted in a way that would have held it together a bit more than it has done?

Ann Keen: I understand where you are coming from with that question, but the legislation on patient charging made that difficult. To actually have had two different parallel charges at the same time would have been difficult and in fact, from my understanding, it would have been against the legislation.

Dr Cockcroft: I was involved a lot with PDS from 1998 and the whole thing about pilots is to learn what works and what does not work. We certainly learned a lot about PDS and some of it is coming true now in terms of simpler courses of treatment and better working with PCTs. However, we also importantly learned what did not work. When we had PDS pilots without a common currency for one year with only 25% of dentists we lost £60 million in dentist charging because there was no currency to monitor contracts. That was only with having 25% of dentists in PDS. We also learned that everybody wanted on prevention but if you just let people do it without any guidance they did a lot of things which were called prevention but there is no evidence base to say that what they were doing was actually doing any good. Obviously the simpler courses of treatment did actually come true and we can see that what we thought would happen and what we learned from PDS pilots is happening now and we were able to say that under PDS we had simple courses of treatment and patient health did not suffer as a result of that. You do not just pilot what works, you pilot a range of things and find out what works and what does not work, and then implement on the basis of that.

Q699 Chairman: I accept entirely about piloting different things and that seems a very sensible approach, but when you went onto the new contract you had not tried it out. Was that because you just felt that the charging regulations could not be changed in an area so a pilot could be done in a comprehensive manner? Why is it?

Dr Cockcroft: Obviously it relates to implementation as well and we were keen not to delay any further in terms of implementation because the fundamental benefit of the contract is that it gives the NHS control over where services are and prevents the development of deserts like the CAB referred to. We were very keen, because of the significant benefit of local commissioning, to introduce that as quickly as possible and had we introduced another pilot without local commissioning in some way the existing situation would just have gone on for longer.

Q700 Chairman: Was it the charging regulations that restricted you, do you think?

Dr Cockcroft: We could not have piloted the exact scheme in one area and left the other scheme working in another area because that would have been against the law, to have different patient charging schemes in one area compared to another. We could not do that. We could have introduced it - which is what we did - and the regulations are very flexible so we can amend and adjust within that flexibility that is there. We continue to do that.

Q701 Chairman: Was there no flexibility to change the law to make sure that what you were going to introduce nationally could have been proved?

Dr Cockcroft: The regulations are incredibly flexible. There is an overarching framework with flexibility within it and obviously at the moment not as many people are being flexible as they want. Once you have changed the law to give PCTs a duty to do it then beyond that you can actually amend the regulations when you actually want to. The fundamental principle was to get local commissioning in as quickly as possible so that we can start to target some areas where there were difficulties.

Q702 Sandra Gidley: I would like to pick up on something Dr Cockcroft said. You said you had had the trials for a year.

Dr Cockcroft: Since 1998 they have been piloted.

Q703 Sandra Gidley: You said patient oral health had not suffered. Can you just clarify how you know?

Dr Cockcroft: My own practice went into PDS in 1998 and the incidents of interventions of item of service had gone down quite significantly. When the NAO did their report on dentistry in 2003 or 2004 they did a little research project comparing the health of patients in my practice and the other two practices with similar practices in Nuneaton (a similar demographic area) and we had less intervention. The NAO did a quick and dirty - I think they call it that - bit of research involving Birmingham University and found that the health of the patients attending in Nuneaton did not suffer from the fact that they had less intervention at all.

Q704 Sandra Gidley: It was very small.

Dr Cockcroft: Yes, it was very small and some of the pilots that started out were very small, but the NAO felt comfortable enough to publish it in their report.

Q705 Dr Naysmith: Good morning, Minister; it is a pleasure to have you before us today. I would like to ask you a few questions about primary care trusts and commissioning. We have had quite a lot of evidence suggesting that there is wide variation between the way some PCTs do it and others. Do you accept that some PCTs are actually currently incapable of properly commissioning dental services?

Ann Keen: What I could say is that there is a variation; I would agree with you. "Incapable" may be a bit strong for the PCTs but there is very, very strong evidence that some PCTs need much more support. It is the NHS devolved; areas are doing it so well and sharing that best practice is so important.

Q706 Dr Naysmith: We had evidence from Sandwell PCT and they have been employing dental consultants within the PCT to try to assess the needs of the patients in their area and so on. That sounds like very good practice.

Ann Keen: Absolutely.

Q707 Dr Naysmith: What are you doing to try to make sure that is happening in other primary care trusts?

Ann Keen: The first thing we have done is make sure that dentistry is in the operating framework of the NHS so therefore PCTs have to take this very, very seriously. I have spoken at conferences with the BDA and with PTC commissioners to stress the importance of how we want to work with them. I do not think we cannot take responsibility for saying that we have changed a contract that has been in place for over 50 years and then not give them support and help. Also a piece of work is now going to be done within our commissioning department at the Department of Health to give much more support where it is needed. I think we have to listen and learn from where it is very good practice, as you pointed out, and where it is not, to make sure that those PCTs are very well supported.

Q708 Dr Naysmith: Do you approve of PCTs using ring fenced money to make-up shortfalls in patient charge income rather than to commission new services?

Ann Keen: In the new world of commissioning we want it to be world class; we want this to change. As you raised ring fencing, I am sure the Committee will be aware that this week I have encouraged, since I have taken up my post in July, I suppose the best way to described it is that ring fencing will continue now until 2011. One of the many aspects I have picked up with this new portfolio and in particular on dentistry was the anxiety around when ring fencing would end in 2009. To be fair to everyone I felt that that was too soon when there has been such a big shift in the way service was to be delivered. I was pleased to be able to get the support of the secretary of state within the operating framework and now, very recently, to have been successful in saying that ring fencing will continue until 2011. I am sure that the profession will welcome that.

Q709 Dr Naysmith: It was just a coincidence that that came out a day or two before you were due to be before this Committee.

Ann Keen: As a former nurse I am sure you would trust me. It takes time to get agreements and I have been working on this agreement and have been able successful to be able to say it this week by coincidence.

Chairman: It is not the first coincidence we have had of things happening prior to ministers coming along to this Committee.

Q710 Charlotte Atkins: Now that a Tory peer suggests that nurses are not perhaps as trustworthy as they might be I am a little bit concerned about your comments.

Ann Keen: I could go on about that but I am sure you will not want me to. I hope the Committee will at some other stage.

Q711 Charlotte Atkins: I want to move onto patient access. We are told that a quarter of a million fewer patients received NHS care in the first year of the contract. Does that demonstrate that the new arrangements are a failure?

Ann Keen: Wherever patients cannot get treatment of course that is seen as a failure but I think we have made great progress. Some of the figures are not the present figures, what is happening today, in the last few months and will be happening throughout the rest of this year. Perhaps Barry would like to comment on this.

Dr Cockcroft: The figures that we produce on access are two year retrospective figures and actually cover the period when we introduced the implementation and we lost 3.6% of service which was equivalent to 960,000 patients. That loss will feed through two years on from when those patients last saw their dentist before April 2006. That retrospective data reflects that loss. If I can give an illustration, the day after I spoke here on 21 February I opened two new practices, one in Tame in Buckinghamshire and one in Banbury in Oxfordshire. Both those practices have got several thousand patients now on their database. They are brand new, very high quality practices, but the patients who are now accessing services there will not actually register on the access data until they have been seen, they have been completed treated and the data actually starts to factor in. The full effect of new practices - I am opening practices all over the place at the moment - will not show for two years after their opening. The access data that you are showing at the moment does not reflect what is happening now, it actually reflects the long term impact of the loss of service that we had in April 2006. We took a very high profile media hit on losing 3.6% of service in April 2006 and we are now taking the hit again for the same patients as they show up in the data. The current situation is positive, it is growing but it is probably not growing as fast as we would like it to do in some areas. However, the picture on the ground now is not reflected by what that data represents.

Q712 Charlotte Atkins: The Department was clearly so worried about the issue of access that the original decision not to allow dentists to go private but to treat children on the NHS was at some point rescinded and you allowed that to proceed. Why was that?

Dr Cockcroft: I think the issue was that we were not starting from a clean sheet of paper. Under the old system you had a significant number of children who were seeing dentists privately either because their parents were in a private scheme or because they were told they had to. We certainly do not want to grow any more child only contracts - I do not think they have a place in long term commissioning plans - but if we had actually said you cannot do that there would have been a loss of access for some children.

Q713 Charlotte Atkins: You did say initially that you could not do that.

Dr Cockcroft: It was in the original proposals but we realised that if we implemented it like that it would cause more difficulty. The decision was taken before we published the regulations.

Q714 Charlotte Atkins: When was the change made?

Dr Cockcroft: We always knew there would be some loss of service and it did not turn out to be as big as some people predicted, but we also realised that if we did that we would lose children and children would lose access. The NHS would have the ability to re-commission and the Patients Association report today shows how well PCTs did at finding new places for people. There would have been discontinuity of service for children at that point. It was a pragmatic decision. If we were starting from a clean sheet of paper we would not have allowed restricted contracts I do not think, but we had children who were already in that situation and to make those contracts not allowable would have actually disenfranchised a significant number of children at that time. In the long term they would have found new places, but I think it was felt that that was not the right thing to do over the transitional period. We are now trying to get more stability and certainly people are not now agreeing new child contracts anywhere.

Q715 Charlotte Atkins: They are not agreeing them or they are not allowed to agree them?

Dr Cockcroft: They are not agreeing new ones. PCTs are very clear that they are not agreeing to new child only contracts.

Q716 Charlotte Atkins: Is that against the rules or are they just choosing to do that?

Dr Cockcroft: PCTs have discretion to do that where they think it is appropriate. I have had many e-mails from PCTs saying that they are not going to invest in any more child only contracts. I think that is one thing that is quite clear. I have said that lots of times; in our guidance we have said that lots of times. The contract that offers services that are restricted, whether it be child or whether it be ability to pay or something like that, I do not think has any long term place in the PCTs' commissioning plans.

Q717 Charlotte Atkins: You mentioned in the press that you thought there had been an increase in private practice, especially for cosmetic treatment. I think you were talking about a number of young dentists leaving the NHS. Given that the Department does not collect statistics on the private sector how did you arrive at that conclusion?

Dr Cockcroft: First of all, that coverage yesterday was based on the income of 53 dentists who are young principals and certainly not representative of the vast majority of young dentists. I go around and I am always visiting practices, I have good connections with the dental schools and anybody understands there has been a growth in cosmetic dentistry over ten years and that is not a bad thing. I think the important thing is not that every dentist stays in the NHS; the important thing is that there are enough dentists to provide the NHS services that PCTs want to commission. Everybody keeps going on about what a bad contract this is, yet every time a primary care trust goes out to tender now there are dentists queuing up to provide those services. The big corporates have said they are committed to the NHS; there is no shortage of people wanting to grow their NHS commitment. I see that all the time. Certainly there has been an explosion in the private sector, most of it in terms of cosmetic surgery such as whitening and implants; you cannot be a newsreader these days unless you have sparkly white teeth, but it is not appropriate for the NHS to do that. I do not see any problem with that, especially now that the growth in the private sector does not mean a reduction in funding in the NHS.

Q718 Charlotte Atkins: Can we also now go onto the issue of waiting lists for dental treatment. The Department does not think it is necessary to record waiting lists despite the fact that many NHS dentists are full to capacity and therefore are not recording a waiting list. Do some PCTs keep waiting lists or do they not?

Ann Keen: PCTs have many helplines and many ways of helping patients to access dentists; there are some very imaginative ways of helping them to access dentistry. However, it has never been felt necessary to have the waiting list system incorporated into dentistry. When I looked into this the evidence that comes back to me is that there is no need for that waiting list because you should be able to access a dentist that week, therefore keeping a waiting list is not appropriate. Barry has done some work on this.

Dr Cockcroft: Waiting lists relate normally to when there has been a referral to secondary care; individual people make a judgment about when they want to go to a dentist. You would not have a waiting list to see a GP. There are many PCTs in the country now where access is available immediately and we have a lot of examples now of PCTs advertising. I was in Plymouth the other week where the PCT advertises both through NHS Direct and in the local newspaper saying, "Ring our helpline and we can provide you with care". It is not something that every PCT needs to do anyway. I think the important thing, where there has been a shortage and we accept there has been in many areas, is that PCTs keep a database of people who want to access care there and then and the PCT can then provide them with those spaces. The idea of having a waiting list for primary care which people do not get referred to but just decide when they want to go does not seem to fit comfortably with a model of waiting lists and hospital referrals.

Q719 Charlotte Atkins: If you have a town in a relatively rural area it is not surprising for people to be waiting for maybe ten years for an NHS dentist. I even have a waiting list on my books as an MP. Devon PCT has told us that they have 7,700 patients on a waiting list.

Dr Cockcroft: They used to have 50,000. Where they need to do that, holding a list of patients who want to access services centrally is a very good idea. Most PCTs are doing that when they are growing their services. The idea of just having a national scheme for waiting lists does not seem to us to be reasonable.

Ann Keen: There are also dentists who are advertising for patients. In Lewisham and Nottingham they are advertising for patients to come for dental care. What we want is for you to get your appointment when you want it.

Mr Lye: Lewisham is a really interesting example because if you look at the access figures from March 2006 when the new system came in then the access in Lewisham is actually slightly down - not hugely down, but slightly down - but the PCT says they have 36 practices who are able to take on new patients. I think we talked about this issue last time we were here, about how you marry up the patients with the access availability that you have.

Q720 Charlotte Atkins: Meanwhile my PCT is very concerned about introducing a new dentist in such a way that they do not have a queue going a mile down the road.

Dr Cockcroft: Having to queue round the block is not a good way to access the system. You may remember in 2003 there was a well publicised queue and we produced some guidance for PCTs which said that it is not right and it does not reflect well. If people want to access services they should come in, the PCTs should hold a database, they know when they register their interest so that people can be treated in the order they were seen and can be managed well at primary care trust level. The vast majority of primary care trust level where they have that issue are actually keeping waiting lists and have actually got dentists who all the time will say that they can see some more patients now and then the PCT directs them to those services. I think we were nowhere near that three or four years ago. I think the way that has developed over the last three or four years has been a really excellent feature of PCT commissioning.

Q721 Dr Naysmith: There is no doubt that there are now dentists who are looking for patients and there is more NHS dentistry available. At the same time there are still some dentists who are switching over to purely private treatment; there is one in my area who has just done it recently. Are we winning or losing on the balance?

Dr Cockcroft: That happens and that has always happened. The big difference now is that there are no questions about workforce. Everybody accepts that the workforce situation is sorted. I was in Plymouth last week where they are advertising for patients. They did have a practice do that. I spoke to the NHS Commission and she said that it was disappointing, but they were able to find places for everybody with other practices who wanted to grow their services. We know that the level of commissioned services by the PCT is now much higher than it was before April 2006 so, as I said, we know the thing is growing now but it will take some time for it to show through in statistics. There is no workforce shortage and there are enough people who want to provide services if the PCTs offer them for tendering. The disappointment in some ways is the pace at which PCTs are actually doing that. I think the pace is disappointing and I think that reflects the difficult relations in the profession over the last year as well.

Q722 Dr Naysmith: That is very encouraging but I caution you when you use the phrase "it is sorted", particularly if you are referring to workforce planning in the National Health Service.

Dr Cockcroft: I was told there was no such thing as workforce planning.

Ann Keen: I think 170 extra dentists will actually graduate each year. That is so encouraging and in the next two to three years we will see a huge change in our dental services. It is worth putting on record now the work that people are doing to work this contract, the way our dentists have worked with us has been tremendous. Yes, I know the media has given some interesting publicity at times and I was at the forefront of receiving this, especially the gentleman who removed his own teeth with a pair of pliers. That is media sensation but the reality is that 170 new dentists graduate every year and that is just great news for our national health service and the dental service.

Mr Lye: Barry has made the point that the access figures look back over two years. He has been talking about what is happening now. Then we look forward to next year and beyond with dentistry and the operating framework and with the 11% increase in funding. What we will see towards the end of this month are the plans that the PCTs submit to the SHAs to show what they intend to commission. We have been getting out and about to see what is happening and certainly the inclusion in the operating framework is raising the importance of dentistry alongside the importance of the extra money that is going in. Some SHAs are really starting to grip this now and they are actually requiring the PCTs to do some of the things that I know members of this Committee are concerned about like going out and doing the oral health needs assessments and consultations and actually doing their commissioning in a planned way. We need to see what comes in in March but I think the message is there that this is important, we are taking it seriously and we are going to performance manage it.

Q723 Stephen Hesford: I understand there is a new dental school opened in central Lancashire.

Dr Cockcroft: There is one in Plymouth and one in central Lancashire which has links to Liverpool.

Q724 Stephen Hesford: They are the first for about a hundred years.

Dr Cockcroft: I could not find any data relating to when the last one was opened.

Q725 Stephen Hesford: In terms of workforce planning what is the expectation that they will add to the system?

Dr Cockcroft: We had a workforce review in 2004 which showed a gap between need and supply and we made a decision then to increase the workforce. Part of that was the increase in undergraduate expansion that Ann talked about. The existing dental schools initially took the whole tranche so that we could implement the 170 increase straight away and it has taken time for the two new dental schools to open; they are open now. The 170 extra UK graduates every year will have a very significant impact on growing our dental workforce. The other thing is that at both the two new dental schools the clinical teaching actually goes on in the community in primary care, so in Plymouth you have four outreach teaching units. In Lancashire they are based in Carlisle, Blackpool, Accrington and somewhere else that I cannot remember and they are co-located with other services. Even while the students are being taught services are being developed at the same time in the locality. This is the right thing to do because 95% of dentists end up in primary care anyway.

Q726 Chairman: Obviously with the opening of new dental schools we are going to have a bigger dental workforce. We have it at the moment with medical doctors at the moment; you will be aware of changing the regulations and everything else. A note has just been passed to me about a comment from a former head of the dental section of the World Health Organisation that a hungry dentist is a dangerous dentist. Given that there are going to be so many of them, are you worried that?

Dr Cockcroft: I think people made that comment in the mid-80s and subsequently closed two dental schools in 1988 and we have been reaping the rewards of that decision. I think everybody thought it was the right decision to make at the time, but clearly it was the wrong decision to make. Making assumptions like that are very simplistic. As the older population continues to retain its teeth the need for services will continue. What we need to do is get the workforce appropriate to the need. A wild oversupply or a wild undersupply is bad in different ways; we need to get it just about right.

Ann Keen: Maintaining your own teeth is so important. I believe there are statistics around that in the 1970s one in three of the over-60s did not have their own teeth. There has been a massive change in the importance of oral health.

Dr Cockcroft: Under the old system a hungry dentist was a very dangerous dentist with an item of service based system.

Q727 Chairman: The other thing that Doug mentioned a few minutes ago was the issue about the profession. The relationship with the profession has certainly not been good. We took evidence both in this inquiry and a previous inquiry about the Department's relationship with the profession. Is it any better than it was two years ago when you walked out of the negotiations?

Ann Keen: I hope so because I have met with the BDA and we have had a very good meeting. In fact somewhere in this pile of papers I have the letter thanking me for the meeting and saying that we are now where we are and they are looking forward to working with myself and officials to progress the contract. I think it is very important that we recognise how difficult it has been and that is what I was able to do as a new minister coming into the contract. They gave me the courtesy and accepted that. I accepted an invitation to a conference. I want to work with the BDA along with other professions related to dentistry the same way as I work with every other part of the NHS. What is so important is that we actually recognise the importance of their work. It is not just about drill and fill - as is often said - it is much more than that. We do recognise the professionalism of a dentist, the quality of the work they do and also, by us having regular oral checks, other more serious conditions can be diagnosed by the dentist and the rest of the oral health care team. This has a different standing; it is a very professional team and the public are recognising that. Our 12 year4 old children's teeth are the healthiest in Europe. We are doing work around fluoridation and we are working together with big companies like ASDA. ASDA are working with me and with the BDA on looking at how they can promote fluoridation varnish with children. We are working very positively together and that is the relationship that I and officials now have with the BDA, recognising there was difficulty but I do believe the BDA would say that we have started to overcome that.

Dr Cockcroft: Although we have had a very sticky relationship with the BDA over the last couple of years, when you actually get out a lot and meet the individual dentists who are growing their services and making the thing work, the relationship is a lot better there. The practice I opened on 22 February would be very happy for any member of the Committee to go and visit them and speak to them. In the Chief Dental Officer's update which I published this week there are examples of providers who have been able to say that this has worked really well for us, this is what we are doing and we are taking it forward. I do not get any negative vibes when I go and meet the profession and I do that on a very, very regular basis.

Q728 Chairman: So you think it has improved.

Dr Cockcroft: Yes. I think it was a very fraught time and whenever I go and meet dentists I always say that I realise how difficult it was, there was a lot of misleading propaganda, there was a lot of stuff that made people worry, inappropriately worried about 2009 and we have started to address that now. I was really pleased that the Patients Association's report published this morning showed that 92% of primary care trusts were actively involving dentists in the development of service. When that happens that is when you get the really good relationship. I was not expecting to welcome the report but if you look not at the conclusions - which did not seem to be based on the report - rather at the data and the returns from primary care trusts it is very, very positive - the number of PCTs who have found places for people who have lost access, the amount of money that is being retained in dentistry - it was a very positive report.

Q729 Chairman: Barry, you said you were recently in Plymouth. The southwest is one of the areas that we have been told where, along with one or two other areas, access to orthodontics is not very good. Can you tell us what the Department is doing?

Dr Cockcroft: Orthodontics is one of the trickiest issues because the inequality in orthodontics services was much greater under the old system than it was for general dentistry. Someone once said to me that there were 21 specialist orthodontists within one mile of Guildford centre but there was not one within 21 miles of Middlesbrough town centre. That was caused by the old system. PCTs now have a duty to provide and commission orthodontics. We know from our own data there is a very significant increase in commissioning of orthodontics going on because that is appropriate. It has to be based on need, not just open access for anybody who just thinks they have a slight twisted tooth that needs straightening. My deputy yesterday met with the Consultant Orthodontic Group to talk about 18 weeks. They were very positive about taking this forward. Most orthodontics needs go on in primary care. It is about developing local clinical networks and Tony was speaking to a consultant from Taunton who was saying how well it was going, developing a local clinical network down there. The old system got us into a really sticky situation around orthodontics, even worse than generalist dentistry, but we have given the PCTs a duty to sort that out and they are sorting it out. The fact that orthodontics is in the 18 weeks thing would actually give an added impetus to people to actually improve that.

Q730 Chairman: Are you measuring what is happening?

Dr Cockcroft: Yes, we have commissioning data for orthodontics and we know the extra commissioning for orthodontics is going on now.

Q731 Sandra Gidley: We heard last week that with the 18 week target there was a possibility that patients would be bounced back out of the hospital system and referred back into primary care. I spoke to a person in the Southampton PCT who commissions dental work and orthodontic work and historically they have a very poor provision level. I am extremely worried that a system that is not coping with primary care at the moment will be put under extra strain when the figures are fiddled to achieve the 18 week target. That is not exactly what they said, but that is certainly the gist.

Dr Cockcroft: The PCTs have a duty to provide bits which they did not have before April 2006 but it will take some time to grow it. What we will need to do over time is see a redistribution of orthodontic workforce. Clearly bumping people out of secondary care into primary care where they cannot access services is not acceptable.

Q732 Sandra Gidley: But it is going to happen.

Dr Cockcroft: We are working very hard with orthodontists. We have a relatively good relationship with them and a very good relationship with the British Orthodontic Society. From the meeting that Tony had yesterday with the Consultant Orthodontic Group the indication they gave was that it would take a bit of time but it can be sorted.

Q733 Sandra Gidley: What do you mean by "a bit of time"?

Dr Cockcroft: You do not want me to make a pledge, do you?

Q734 Sandra Gidley: I would like an indication. "A bit of time" could mean all things to all men.

Dr Cockcroft: It takes time to create new services and it takes time to relocate people but PCTs have a duty to do this and I will not commit to a specific time because it will be quicker in some areas than it is in others.

Q735 Sandra Gidley: Minister, would you accept that it was actually a mistake to allocate resources to PCTs based on their historic level of NHS activity?

Ann Keen: No. We gave a commitment to maintain contract values for existing practitioners and therefore had to allocate resources on historical spend. We had to start by honouring existing contracts and maintaining existing levels of service. That was very important. I believe during the committee stage of the Health and Social Care Standards Bill we were asked to give the important guarantee that current spending will be protected and we gave that commitment.

Q736 Sandra Gidley: That does not help those areas that have a low provision. How is access going to improve in areas like mine, in the Hampshire part of my constituency which has relatively low access? Southampton is fine; they have above average access but that was the historical position that each of those PCTs inherited. In my home time there is no access to NHS dentistry. How is that going to improve if there are no extra resources going into those PCTs with a historically low level of provision?

Ann Keen: I think we would have created chaos had we not honoured it and we gave that commitment in the Bill. I think David wants to say something.

Q737 Sandra Gidley: I want to know how it is going to improve.

Mr Lye: There is a slight analogy with the earlier discussion about children only contracts, that it is not necessarily something we want to have but to have moved away from the historical funding would have destabilised places where there were NHS services in place. The question about "how" I think is how you actually allocate the growth money that is going to be going into dentistry. We made a start this year by using populations as part of the criteria for allocating the 11% that is going in and I think that is the way we have to do it. We have to do it by adjusting the growth so that you move towards a fairer population based system of allocation over time.

Dr Cockcroft: Some of the 11% we have announced is not distributed on historic allocation basis, it goes out on population basis. Areas that have more dentists and a better service get slightly less and the areas like your areas that historically have low allocations we are starting to address that now by making the funding available on a population basis. It will take some time to make progress, to get it completely based on a population basis but we are moving that way now. Under the old system you would not have had the slightest chance of doing that because it would still have been dependent on dentist drawing down the money and in your area where you have access difficulties that would never have happened. So there is a possibility now to make access fairer.

Q738 Sandra Gidley: I am curious as to how this money is going to be allocated because according to the survey that was released today presumably it should be on an assessment of need but I think a third of trusts have not done an oral needs survey.

Dr Cockcroft: I do not know when that survey was done but we have certainly asked all PCTs to do surveys.

Q739 Sandra Gidley: Were these done fairly recently?

Dr Cockcroft: I think it was last year some time; I do not know when.

Q740 Sandra Gidley: September or October.

Dr Cockcroft: We would certainly want them all to do oral health needs assessments.

Q741 Sandra Gidley: How is this money going to be allocated? Is it for PCTs to apply for the money and what criteria are you going to use to boost areas with low supply?

Dr Cockcroft: Areas of low supply will automatically get more funding because it is based on population and not on historical spend. It will happen automatically. It is up to them how they spend it, based on their needs assessment. They do not have to apply for this money; this money goes to them on an allocation basis.

Mr Lye: It is a piece of work that we still have to do.

Q742 Sandra Gidley: So it has not been decided yet.

Mr Lye: We do not yet have a formula to decide how dental funding should be devolved in the future.

Q743 Sandra Gidley: Any idea when we can expect this magic formula?

Mr Lye: No; we need to do that. I would think we need to have at least an idea of how we are going to do it in time for the next round of financial allocations, ie next year's financial allocations.

Dr Cockcroft: It has been refined this year and then as we get the needs assessments done they will indicate areas of higher need it can be refined further. We will be funding on the basis of population this year.

Mr Lye: What we did this year in allocating the 11% was that we allocated a 2% slice of that to the SHAs instead of direct to the PCTs and actually gave them some flexibility to make a judgment about how to allocate that money and some of them have done that on the basis of addressing a particular need and hotspots.

Q744 Sandra Gidley: That does not fill me with confidence. We have heard in this inquiry that most SHAs struggle to find anybody who will admit to taking on responsibility for dentistry.

Mr Lye: I think that is changing.

Q745 Dr Naysmith: Is it an unreasonable question to ask you why you have not got a formula yet?

Mr Lye: No, it is not an unreasonable question.

Q746 Dr Naysmith: What is the answer?

Mr Lye: I cannot give you a totally reasoned answer, but first of all we were, until this year, concerned primarily with keeping the stability as we moved from the old system to the new system. We have now made that move and we do recognise that there are these gaps both in terms of access and in terms of historical funding. We need to put that right and we do need to develop a formula.

Q747 Chairman: So you will give us an undertaking that you will get on with it as soon as you get back to the office.

Ann Keen: I can give you an undertaking that that is definitely what will be happening and thank you for highlighting this to me today in the way you have. This will be very seriously looked at.

Q748 Stephen Hesford: To come back on the idea of access and workforce planning, the CAB said there were two main areas in the country where access was difficult, the northwest and the southwest. We have heard about the new dental school in the northwest. Am I right in thinking there is going to be a new dental school in the southwest, in Truro?

Dr Cockcroft: The dental school hub building is in Plymouth and that has four outreach clinics, one is in Truro, one is in Exeter, one is in Devonport and the other is in Plymouth. These are outreach teaching centres.

Q749 Stephen Hesford: When will that come on stream?

Dr Cockcroft: The students started this year. The first one to come on stream will be Exeter; I am visiting Exeter tomorrow, that is opening tomorrow. There is a big capital investment gone in there and they are building them in a rotation basis because they do not need the full capacity because these are four year programmes and in the first year you only have a quarter of the full complement of students, so you only need build the full clinical teaching capacity over the next four years. I think the Devonport one might be the next one and then it might be Truro, or it might be the other way round. That is a growing programme over the next four years. I have visited the school myself last week and I am very impressed with the way they are planning and developing it.

Q750 Dr Naysmith: Minister, the impression has been given this morning that things are getting better and I think there is a lot of evidence that that is the case. However, how do you account for the fact that there has been a 60% increase in calls to NHS Direct from patients requesting dental related advice and are complaining about tooth related pain? That is between 2003 and 2007. Why do you think that is happening?

Ann Keen: I think that is an awareness problem that PCTs have in the main now started to address. The public do use NHS Direct very well and we thank them for the work that they do. For many people it is their first point of enquiry, whereas there is so much activity with PCTs that have public meetings, information meetings, information leaflets in libraries, in bus stops, advertising posters, on buses. We have got through the worst of people not being aware how to contact someone for dental treatment.

Dr Cockcroft: In many ways the increased use of NHS Direct is actually a good sign of commissioning working. I went to Manchester where nine PCTs have commissioned triaging of out of hours care through the centre just outside Bolton so that anybody who needs care out of hours is directed to NHS Direct. NHS Direct triage those calls and then re-direct them to the Wong Practice in Greater Manchester which has a contract to provide out of hours service or, if it is not urgent, directs them to open access slots in other contracts which the PCT has agreed. In Plymouth the PCT are using NHS Direct in their advertising for patients to ring NHS Direct so that they can signpost them to practices which are accepting patients. So far from the growth in calls to NHS Direct to say it is not working, it actually shows how well PCTS are doing. In Manchester I went to the call centre with the local PCT and with the dentist who has the contract to provide services and they showed me the number of calls that they handle. They are all disposed of appropriately so the patient gets the treatment they need.

Q751 Dr Naysmith: Is there any record of why they are ringing up?

Dr Cockcroft: Many of them, like I say, are directed and a lot of out of hours lines use NHS Direct to triage. If you wanted we could try to dig a little bit deeper and speak to NHS Direct.

Q752 Dr Naysmith: If there are figures it would be useful. The other aspect of this of course is that some people complain of facial pain and dental related pain so it may actually be a lot more than a 60% increase. It would be nice to know what is going on.

Dr Cockcroft: We will try to get that for you.

Q753 Dr Taylor: Minister, I have a terrible fear I am living on a different planet from everybody else. I do not know how Dr Cockcroft can go - unless he is wearing his rose tinted spectacles - and say he gets no negative vibes. Every time I sit in the dentist's chair I get negative vibes and we have heard the same from other members. I want to explore UDAs because we have heard of a lot of problems with UDAs and I want to know what you see as the flaws with UDAs and then if you do not pick them up I will pick them up. What flaws have you seen?

Ann Keen: I am not wearing any rose tinted spectacles or rose tinted contact lenses in my case. What we are seeing is of course a much more simpler payment system from that very complicated system with hundreds and hundreds of different payments. I think most patients feel very confident that they know what they are paying for. I know that Barry and possibly David want to talk about a particular aspect of this because they have brought this together and therefore their knowledge on this particular aspect is better than my own. I do want to say straight away that of course there are variations in the dental contract but we have come through the worse aspect of it. That is what we believe and we know that there is much more to do in some areas, in particular around this particular question of the UDAs. I know the work that David and Barry have been doing they would want to share with you today.

Q754 Dr Taylor: Can I pass onto you a suggestion that we had last week because there are very severe criticisms of the banding and the amount that has to be done under number two band, for example. One of our witnesses last week made what struck me as an incredibly sensible and easy to carry out suggestion, that we should move to either five or eight bands. He suggested splitting band 2 into 2a and 2b; this would not cost that much more because band 2a would only get two UDAs whereas band 2b would get four UDAs. Then again splitting band 3 into 3a with seven UDAs and 3b with 15 UDAs which would allow for the huge differences that at the moment fit within the same bands. Could there be any consideration of that sort of widening of the bands?

Dr Cockcroft: We have had a lot of suggestions ranging from expanding it to five bands to expanding to 400 like the old SDR. I think what we need to do is to let it settle down as it is. To come back to your first point, I certainly do not look at this through rose tinted spectacles and I completely appreciate how angry dentists felt at the beginning. What I am saying is that when I go out now it is a much less aggressive workforce that I am talking to; people still have issues about this and I am sure things will need to change in some areas as time goes on.

Q755 Dr Taylor: So you do still get a few like that.

Dr Cockcroft: Absolutely, especially from people who are in child only contracts who are feeling particularly squeezed at the moment. I think what we learned from PDS was that you need a currency; that was agreed. When we did the framework document in 2003 the BDA said that we needed a clear, identifiable currency and we came up with weighted courses of treatment. We came up with weighted courses of treatment over about six months of discussions with the BDA in 2004. We had a little working group - which I was not on - with three people from the Department and three people from the BDA so the monitoring currency was based on weighted courses of treatment. There was never any grief expressed around that at the time. The UDA is just a measure of the weighting. This is not about creating units; it is about providing treatment based on courses of treatment. You talked about splitting band 2 into 2a and 2b; that would mean raising the value of 2b and dropping the value of 2a. There are far, far simpler cases in band 2. If I went to the British Dental Association or indeed to the dentists and said that we are going to reduce the simpler courses of treatment by X there would be another riot because they would say they do more of those and only do a few of the others.

Mr Lye: The more you increase the number of bands then potentially the more you complicate the system of patient charges.

Q756 Dr Taylor: That would not alter patient charges at all; they would stay the same.

Mr Lye: It potentially would because if you are basing the patient charge rates on the current bandings - which is certainly what we do at the moment - it would be quite difficult to calibrate the patient charges when you have all these different bands.

Q757 Dr Taylor: If they could stay on just band 1, band 2 and band 3 they would not have to alter. We were told again last week that UDAs for some dentists are worth precisely £16 and others are worth over £40.

Dr Cockcroft: The value of the UDA as it started is purely a construct of how dentists worked under the old system and all it does is illustrate how differently dentists worked under the old system. My own view is that the main problem with UDAs is that people have actually focussed too much on UDAs. There are other issues that you should look at in commissioning a quality service, we have some PCTs now looking at saying, "The value of your UDA could be £10 but we will actually give you the rest of your contract value according to quality, access, working with the PCT, clinical governance". That is completely doable within this system without making any regulatory change at all. There was a very rigid transition which focussed completely on UDAs. Everybody needs to get away from that and start to use the flexibility that is in the contract to work in a more flexible way. As the Minister said at the beginning, some PCTs are starting to do that and do it very well now but some are clearly not. The dentists were actually told by their leaders that this is a rigid target based system, yet in June 2007 the BDA produced a guide to innovative commissioning which I though was a fantastic document.

Q758 Dr Taylor: So if the test period when contract barriers were arrived at was a very poor one, for instance you were on maternity leave -----

Dr Cockcroft: With maternity leave you would have got the money and your contract value would not be changed at all.

Q759 Dr Taylor: I have received an e-mail this week from one of my dentists: "I was pregnant at the beginning of 2004; I was on maternity leave for the majority of the test period when contract barriers were arrived at. I ended up with a very low UDA value which often means that the treatment I provide literally leaves me out of pocket." Is there any way round that?

Dr Cockcroft: If somebody was on maternity leave and getting maternity payment, the maternity pay would have been built into the contract value.

Q760 Dr Taylor: So maternity pay should have been built into the contract value.

Dr Cockcroft: If it was what they earned at the time.

Q761 Dr Taylor: Thank you; I shall take that up locally.

Dr Cockcroft: If she had a break in service then obviously the PCT can look at that. She will need to discuss that locally with the PCT. Certainly in some areas now PCTs, because of their 11% growth in areas where access is not a problem, are looking at some of the low UDA values and seeing what they can do. They have the flexibility to change that. It is not about just giving somebody extra money; it is about giving extra value in return for what you are doing, so it works both ways.

Q762 Sandra Gidley: Would you accept that one of the perverse effects of the UDA system has been that in cases of high dental need patients are losing out because there is disincentive for the dentists to carry out complex work? I can give you a couple of examples. We heard from the dental technicians, I think it was, who said that there has been an increase in the number of plates with a single denture and a corresponding decrease in crowns and other more complex and expensive work because sometimes the dentists cannot afford to do that work on the new contract. The survey released today shows that a third of PCTs said they were aware of particular treatments ceasing to be offered by trusts, for example 89.7% of those trusts mentioned root canal work, half of them mentioned bridges, and so it goes on. Is that right? That is a question for you, Minister.

Ann Keen: That is a very technical question and, to be fair, I want this to be answer correctly and this is why Barry is here today, to answer the technical side of dentistry.

Dr Cockcroft: Dentists have a responsibility to provide what is clinically appropriate for their patients. It comes back to Dr Taylor's point that everybody will complain that they cannot do a root canal economically under the new systems but nobody complains that they get paid £70-odd for a very simple course of treatment only involving one filling. It is about swings and roundabouts and not looking at every individual course of treatment in terms of what you get. I would expect a clinician to rise above that sort of thing and to provide clinically appropriate treatment for their patients.

Q763 Sandra Gidley: But this is impacting on patients.

Ann Keen: On that point, if it is impacting on patients it is my responsibility and it is not technical. It should not be impacting on patients and I would be concerned about the ethics of that practice.

Q764 Sandra Gidley: My understanding is that it is fairly widespread.

Dr Cockcroft: I think there are two issues here. One is that there is bound to be a reduction in complex treatment because there was a clear incentive under the old system to do more complex treatment because of the item of service based incentive in that system. The reduction in very complex treatment is appropriate if it is clinically appropriate. The Dental Laboratories Association keep going on about these single tooth dentures and when we raised that at the key stakeholder group none of the dental members on the key stakeholder group recognised that situation and I think it might be apocryphal. I think the other situation is that the Dental Laboratories Association - there is a similar situation in America - where globalisation of supply and movement of laboratory supply to China, to Turkey or to other areas like this is seriously impinging on dental laboratories at home. I had a letter from a dental technician this week who is not politically astute or knowledgeable who actually said that the contracts had an impact, something else had an impact but the main impact on his business is the fact that dentists are now sending their technical work abroad. That is a big problem and it is exactly the same problem in America; American technicians have got exactly the same problem. That might be an issue for us because you never quite know who is going to guarantee the quality of that. However, a reduction that is appropriate is appropriate. If somebody is not providing what is clinically appropriate - root canal is a classic example - that is a governance issue, that is an issue for PCTs and ultimately it is a breach of contract.

Q765 Sandra Gidley: I would just challenge you that it is apocryphal because I would not like to think that we had people coming before our Committee providing apocryphal evidence.

Dr Cockcroft: Some of the stories I have heard have been apocryphal, I know that.

Sandra Gidley: There was evidence to back up this strange coincidental increase in the number of single denture plates with the introduction of the new contract. That may or may not be apocryphal, I do not know.

Q766 Chairman: Do you think that UDAs are the best way of paying for a dental practice to invest in its capital and everything else? When dental practices are used as outreach training practices they are also just paid by the UDA system as well, or am I wrong on that?

Dr Cockcroft: We said in our PCT guidance that we published in January that value for money looks different in different situations. This is a classic around the salaried services where a salaried service can spend a whole morning treating two autistic children. That is incredible value for money for those children but it would not generate very much in terms of UDA. It would be completely inappropriate to performance manage that sort of service using UDAs. It is there as a monitor because you know what patient charges should be. With undergraduate education we have examples of outreach teaching in Sheffield; we have visited two practices in Sheffield where they are working with the PCT and the dental school and a part of their contract is to provide outreach teaching and does not have to be monitored by UDAs. The patient charges need to be provided like that. It has not actually stopped the development of outreach teaching. People are finding ways to get round it flexibly locally.

Q767 Chairman: My understanding is that the payment of UDAs to these practices is reimbursed by having these students getting experience.

Dr Cockcroft: I do not know the particular case and I know you took evidence from Mrs Naylor, but certainly I went to a practice in Sheffield where they have a well-developed outreach centre and they have got UDAs built into the contract but there is other stuff beyond the UDAs in the service level agreement for trainee students.

Q768 Chairman: You believe it is a right and proper way of reimbursing a dental practice for having students.

Dr Cockcroft: I do not think undergraduate training should be directly linked to UDAs, no.

Q769 Chairman: Mrs Naylor's practice is next to the GP practice in the village in my constituency. The GP practice within the GP contract gets money for running that practice or paying its bills etc. Mrs Naylor does not, why?

Dr Cockcroft: This is something we are addressing now in the next stage review. One of the things we will be talking about is around capital and how you invest in premises. Dental premises have been under invested from a capital point of view for years. But doctors' good will was bought out in 1948 and dentists' good will was not bought out in 1948. The mix of NHS and private in dentistry makes it sometimes difficult but clearly getting the NHS to invest capital in improving dental premises is a huge priority for me. We have made £100 million directly available over the last two years; that is very welcome but I think the NHS needs to invest more of NHS capital in improving the NHS dental estate. It was much trickier under the old system because of the contractual arrangement; it starts to become a lot easier now.

Q770 Sandra Gidley: Dr Cockcroft, picking up on something that Dr Taylor said, he has heard that different dentists within the same practice have different UDA values. Correct me if I am wrong, but a PCT has an allocated number of UDAs they can use.

Dr Cockcroft: No.

Q771 Sandra Gidley: They do not, okay. Something that is happening now is that the activity of dentists who are leaving the service is being reallocated, new dentists can tender for it. It is coming in at a much more expensive price. To give a practical example, a dentist who was on a very low UDA value of something like £16 or £17 (which is much lower), when he retires and the PCT re-tendered every bid that came in was well over £20 for the same work. You only have a fixed pot of money so the amount of activity will surely decrease. How is that going to increase access to dentistry in the long run?

Dr Cockcroft: I do not think the amount of activity would decrease.

Q772 Sandra Gidley: There is a cost to this.

Dr Cockcroft: One of the complaints has been that newly tendered services are actually cheaper than the existing ones when they do that and that would actually increase the availability of service because you would be able to commission more work. I think the important thing about tendering in UDA values is that it is quality first. A low quality service is not value for money. Again we are well aware in some early stages that some of the tenders did not go like that, and it is not about lowest price wins the tender. It has to be a quality service.

Q773 Sandra Gidley: How can you assess quality before it is provided?

Dr Cockcroft: I have certainly been to some practices which have gone through the tender process and they are providing a service. How can you assess quality before a service has started? You can look at people's plans, their recruitment plans, their facilities and things like that, and also look at their track record. I think it is very important to look at the track record of the provider before you actually give them a new service. If I could just come back to the Chairman's point about capital, the money that goes to dentists is gross money and an element of capital investment is included in the gross contract values. There are expenses that go out of that and some of that expense is to actually cover capital investment that historically dentists have made.

Q774 Chairman: Are there also professionals working within that practice as well?

Dr Cockcroft: Do you mean nurses?

Q775 Chairman: Yes. That is not the same for GPs at all.

Dr Cockcroft: GPs get 70% of their expenses reimbursed and the dentist pays the expenses of his staff and it has always been like that. I think it is 56%.

Chairman: If that is a moving picture, if there is anything more in the next few weeks I am sure this Committee would like to have a note on it.

Q776 Dr Naysmith: Looking at the public health aspects of dentistry, every ten years since 1968 there has been a survey of adult and child dental health in this country, but for this year it has been decided that it will not happen. We had some very prominent experts here at the Committee last week who said that the data they get from these surveys is invaluable and they have recommended to the Department that it should not happen but you have gone ahead and are not holding the survey this year.

Ann Keen: I really do not understand that at all because we are desperate for this survey to take place. The Department wants this survey to take place.

Dr Cockcroft: The responsibility for surveys has moved to the Information Centre. They have a business plan which has been delayed because of that re-organisation but we certainly are absolutely desperate for this to ahead.

Q777 Dr Naysmith: Do you think it will still go ahead?

Dr Cockcroft: I am hopeful that it will go ahead in 2009. There has been a delay because of the re-organisation but I do not know where you got the impression that we wanted to stop this; we are desperately keen for this to go ahead.

Q778 Dr Naysmith: So you are saying that it has just been delayed.

Dr Cockcroft: Yes, absolutely.

Q779 Dr Naysmith: You recommend that it goes ahead.

Dr Cockcroft: Yes. This is the best quality research for overall dental health in the world. We do a child dental health survey every ten years and an adult dental health survey every ten years. We have had significant internal discussions with the Information Centre about moving this forward as quickly as we possibly can. It has been delayed because of the re-organisation in their funding but there is absolutely no doubt that the Department is desperately keen that both decennial health surveys - child and adult - continue as they have previously. I do not know where you got the impression that we did not want this.

Q780 Dr Naysmith: You must know where we got the impression because you are complaining about it being delayed.

Ann Keen: What we are trying to say is that we desperately want this survey.

Dr Cockcroft: We have certainly had very positive discussions with the British Dental Association; the British Dental Association know that we desperately want this to go ahead, they have written to the Information Centre.

Q781 Dr Naysmith: You still have not got the go ahead, that is the point. One of the things that was said last week was that we could do with a lot more better data collected by primary care trusts on oral health.

Ann Keen: Definitely.

Q782 Dr Naysmith: Are you pushing for that as well?

Dr Cockcroft: It is in the public health regulations; they have to do appropriate surveys. We have good data in some areas and in other areas it is not.

Mr Lye: Just to come in there as well, SHAs in the east of England have written to all their PCTs requiring them to carry out these oral health needs assessments as part of the commissioning process. I am glad to see they are on the case as well.

Q783 Sandra Gidley: The way that UDAs are now calculated makes it impossible to collect data on the individual treatments that are carried out. Would you accept that a vital probity assurance mechanism has been lost and that accountability of public expenditure on dentistry has been reduced by this change?

Ann Keen: I do not know that evidence would show that at this stage at all. What we are aiming at, half way through a contract, is still looking at it and doing a big stock take on this just to see exactly where we are, where we are going and where we will be within the five to ten year span that we need to have. On the last point that Dr Naysmith raised in relation to collecting that data, it is a requirement that the PCTs collect the data and to continue with that.

Dr Cockcroft: On the first of April we are moving to introducing an enhanced clinical data set. The BDA know about that. It will be introduced on the first of April so we will know more data about what goes on within the individual courses of treatment. It will be item of service, but I have always been confused about the value of item of service data. All it does is evaluate what you have been paid for; it makes no mention of whether there is any health benefit or not. We clearly recognise that PCTs needed more information, dentists need more information because, as you were saying, they need to be able to demonstrate that to the PCTs in discussions. So that will be introduced from the first of April and it will include the two items of evidence based prevention that we know can actually be done in practice and will work. For the first time ever we will be recording preventive activity on an official NHS form.

Q784 Sandra Gidley: I think we are coming onto preventative activity later. Will you accept that the data is different so it is going to be much more difficult to compare what is happening after the introduction of the contract with what was happening before?

Dr Cockcroft: We certainly do not have item of service data. A lot of people go on about the research value of item of service data. I do not think there is any link between oral health and item of service data and we are comfortable with that. We need to measure oral health, that is the important thing. The reason we had such good data on item of service was because that was how we paid the dentist previously and everybody agrees it is an inappropriate way to pay dentist, especially without ever improving oral health. A lot of people comment on that but I think their argument is fundamentally flawed.

Q785 Sandra Gidley: So what is the role of the Dental Reference Service going to be in the future?

Ann Keen: Enhanced.

Q786 Sandra Gidley: We had evidence from John Taylor who said that it was exercising an increasingly pastoral role.

Mr Lye: They have just carried out a consultation on the way they plan to change their role. They have talked to us and to the Welsh Assembly Government and they have talked to the NHS as well. What they are proposing to do is to move towards a system which is a sort of risk based approach to monitoring. Let me put that into plain English. It is where they actually look at the information that is coming in so, for example, the information that they get from the clinical data set, from the FP17 forms, from the information they get through the claims they receive for payment online, any intelligence they get from PCTs and so the routine inspections and monitoring that they used to do will be on a less random basis and more on a basis where they identify that there are things that alert them to the fact that there may be potential issues there that need looking at. They are still going to be doing an awful lot of work out there in terms of the clinical records. They will be looking at a hundred thousand clinical records a year; they will be doing a thousand surgery inspections a year and they will be targeting particular ones; they estimate they will be doing 500 targeted visits a year where they have evidence that there appear to be anomalies in the information they are receiving. So they are going to have an active role out on the front foot. The other thing they are doing as part of the internal restructuring is to make sure that the dental reference officers who are the clinicians who actually do these visits will be doing less administration and actually spending more time on visits and assessments.

Dr Cockcroft: John Taylor left the DSD in 2006; this work has all gone on since John left the DSD.

Q787 Dr Taylor: We were told last week that the dental reference officer examines records but the records that they examine are selected by the dentists themselves.

Dr Cockcroft: That is what went on through the PDS piloting. They are going much more now to targeting and requesting named records rather than just asking them to supply the ones they like.

Q788 Dr Taylor: So in the future they will be able to go in and pick out any at random.

Dr Cockcroft: Yes.

Dr Taylor: That is reassuring, thank you.

Q789 Charlotte Atkins: I want to move onto the issue of preventative care but first I would like to congratulate the Minister on the announcement on the fluoridation of water supply because I think that will be a huge step forward for oral health and we will see the impact of that in just a few years' time hopefully. Witnesses have been saying to us that the dental contract should contain extra incentives to dentists to provide more preventative care because at the moment that is obviously not covered by UDAs. Are there any plans to modify the contract? I know that Barry Cockcroft was talking earlier about the fact that there are developments outside the UDA framework, but what sort of modification of the contract are you going to be introducing to ensure that you are not just relying on the good PCTs to actually explore that preventative area but actually to introduce an OF-type system for dentistry because clearly we cannot expect the worst PCTs to come up to the best immediately and we do have to provide the wherewithal for dentists to be able to provide that preventative element, particularly in areas of very poor dental health.

Dr Cockcroft: Preventative activity is within band 1 so it is there and it is expected to be provided. A lot of the evidence based preventative stuff that is in our guide that we sent out can actually be done by DCPs, by dental nurses and fissure sealants by therapists and things like that. Developing the role of skill mix is a key part of what we are actually doing. Like I said earlier on, within that enhanced clinical data set that starts on the first of April the two best evidence based procedures - fissure sealant where there is a clinical need and the application of topical fluoride - will be recorded on the clinical data set. So a PCT that may not be actively monitoring will actually get a report from the DSD which actually says that none of the practices have actually done any prevention. As the Minister has said, there is variation but this will be so blindingly obvious to them that something is not actually going on that they should, as good commissioners, be challenging that. What we are actually doing is working to develop preventive things with people who traditionally do not access care. The Minister talked about the initiative with ASDA which we are working on at the moment to try to get preventive treatment delivered in the non-dental surgery environment because a lot of the people who have the most needs would not go near the dental surgeries to save their lives.

Ann Keen: I think a QOF-type system would be a very positive way forward. Lord Darzi in his review is trying to bring dentistry into the mainstream of primary care and that is where I personally feel it should be. The fact that it has been seen as separate is not acceptable any more. The inequalities in dental health are still so very, very obvious and the only way I think we can go forward with this is to bring it right into the centre of the primary care setting, whether that is back to capital spending on where the dental surgery is, and it is something that when we go into a clinic we expect to see the entire primary care team there and that that is quality measured. The dentist sits in the centre and the hygienist and the nurse and the entire dental team sits in the centre of the primary care team.

Q790 Charlotte Atkins: I very much agree with you but very often the issue is for dentists to be able to find the appropriate premises and they do not really get much support. I know from a new dentist in my patch, trying to find the appropriate dental premises, having to compete maybe with a property developer for the same property, and also what incentives are there to ensure, once they have a premises with sufficient space, to actually encourage the use of a range of other dental professionals to do that important preventative work. At the moment there does not seem to be very much incentive for that to happen.

Ann Keen: That is an area we want to work on. I think Lord Darzi's review will assist us in doing that, along with your report that will assist us in being able to do that.

Dr Cockcroft: I completely agree with what you are saying about capital. It has been a longstanding problem in dental premises being under-invested in capital for a long time. I think there is an opportunity to do something now. You were talking about QOF and one of the things you could do within QOF is include something that says, "Do you involve dental care professionals in your preventive work? Are you doing that now to provide better service to patients?" PCTs could decide that locally and it can be done. Topical fluoride varnish can be applied by dental nurses if they are competent and trained; it does not need a dentist to do it. Obviously fissure sealants can be done a therapist. It can be developed locally. If you have an area of high need as well you can actually include in the contract a targeted incentive on people of that postcode area and you can put some extra money in to support that if you wanted to do it. I think in West Yorkshire they provided free fluoride varnish for their practitioners in the worst area in Kirklees so that the dentist has at least a bit of financial support right at the very beginning; it was a small drop but it was going in the right direction.

Q791 Charlotte Atkins: We all agree that we must have evidence based policy.

Dr Cockcroft: Yes.

Q792 Charlotte Atkins: So how are we going to make sure that the preventative programme is actually properly measured and monitored to make sure that we have an even-handed approach across the country and we particularly focus on those areas of great dental inequalities?

Ann Keen: That is where the QOF system wil